For both, at risk for bleeding and clotting!! Clots can be arterial or venous!! Also at risk of ischemia (eg strokes) from hyperviscosity

Treatment for PCV:

Phlebotomy to maintain Hgb<15 + low dose ASA

If symptomatic, high risk of thrombosis or progressive myeloproliferation (splenomegaly, leukocytosis, thrombocytosis) à cytoreductive therapy (hydroxyurea as first line, interferon if contraindications to hydroxyurea)

If thrombosis à anticoagulate! (UNLESS they have mesenteric ischemia from thrombosis – want to r/ GIB before starting anticoagulation if worried about this!_

When you see polycythemia, check JAK2 and EPO levels. High JAK2 suggests a primary myeloproliferative process; high epo suggests a secondary process. See the diagram below!

Thanks to Izzy for sharing 5 malignancies associated with high epo levels:

Remember there are 4 grades of hepatic encephalopathy (that you can look up!):

Grade I – change in behavior, sleep cycle reversal, hyperreflexia

Grade II – disorientation, lethargy, asterixis

Grade III – marked confusion, obtundation

Grade IV – comatose, unresponsive, loss of reflexes

Ammonia levels can be helpful in prognosis!

Most common cause of mortality is cerebral edema leading to herniation!! Minimize this with elevating head of bed, hypertonic saline, mannitol.

Other things to watch out for: high risk of infection, risk of hypoglycemia (from impaired gluconeogenesis), electrolytes, renal dysfunction, bleeding

Indications to TIPs – typically, used to treat major consequences of portal HTN (variceal hemorrhage, ascites); also can consider for Budd Chiari (though indication is less clear). Remember that this increases the risk of hepatic encephalopathy!!